Preventing Acute Malnutrition in South Darfur ... - The iLiNS Project

Preventing Acute Malnutrition in South Darfur, Sudan:
Two Blanket Distribution Approaches in Two
Internally Displaced Persons Camps
Erin Boyd, MPH UNICEF
Leisel Talley, MPH Centers for Disease Control and Prevention
In collaboration with:
State Ministry of Health, South Darfur State, Sudan
World Food Programme, South Darfur State, Sudan
LNS Research Network Meeting
April 8, 2011
Center for Global Health
International Emergency and Refugee Health Branch

Objective
Assess the impact of blanket distribution of Lipid-based Nutrient
Supplements (LNS) and Improved Dry Rations (IDR) on preventing
increases in acute malnutrition during the hunger season on a
population level.

Program Design
Implement blanket supplementary feeding in 2
internally displaced persons camps in South Darfur
during the hunger season (May-September, 2009)
Monthly distribution for 4 months
One camp: Improved dry ration
One camp: Lipid-based nutrient supplement
Follow a cohort of children in each camp on a
monthly basis to assess anthropometric status
Children 6-59 months of age received ration per standard protocol
Only children 6-36 months of age enrolled in cohort

Improved Dry Ration (IDR)
Improved dry ration:
CSB, oil, sugar and dried-skimmed milk powder (DSM)
DSM provided an animal protein
Mixed with water and cooked
Prior to CSB++ production
WFP delivered pre-packaged ready to distribute

Lipid-based Nutrient Supplement
(LNS): Plumpy’doz
Ready-to-Use-Food
Supplement to local diets not meal replacement
Peanut-based, fortified lipid-based nutrient spread
Prevention of moderate malnutrition
Packaged in a 325 gm cup (weekly ration)

Daily Energy, Protein and Fat Content
LNS
(46 g)
IDR
(180 g)
Energy (kcal) 247 785
Protein (g) 5.9 28.8
Fat (g) 16 27.4

Target Population:
Otash (IDR) and Al Salam (LNS) Camps
Both camps within 20 kms of Nyala town
Population
Total
Under five
Otash 70,134 14,027
Al Salam 62,876 12,575
Regular movement between to Nyala for casual labor
Services: WASH, protection, PHC/nutrition (OTPs)
General food distribution

Target Population:
Nutrition Survey Data 2008 †
Intervention
LNS
IDR
2008 GAM
July
(hunger)
19.2
(15.7- 23.1)
19.5
(16.1- 23.5)
2008 GAM
December
(harvest)
7.4
(5.3- 10.3)
9.8
(7.3- 12.9)
†
NCHS reference

Sample size
Methods
Diggle repeated measures longitudinal analysis
Difference in the mean
Minimum sample size 150 children 6 – 36 months of age
Registration of all children

Exclusion criteria
Analysis
LNS : 141 children delay in receipt of distribution
WHZ

Results
Children waiting for measurement, Otash camp

Cohort
IDR
LNS*
Registered 895 754
Excluded malnourished
at enrollment
68 57
Distribution 2 607 318
Distribution 3 441 275
Distribution 4 547 273
Total with 4
measurements
159 187
*One sector of 141 children were removed from analysis because of delayed registration

Sex Distribution
Intervention Boys Girls Boy: Girl
Ratio
LNS
47.17% 52.83% 0.9
IDR
53.48% 46.52% 1.1
Chi square: 1.37 p value= 0.24

Mean Age at Enrollment
Intervention
Mean Age (range)
Standard
Deviation
LNS 24.03 (6-36) 8.2
IDR 23.70 (6-36) 8.3
T-test p value= 0.72

Mean Weight for Height Z Scores (WHO 2005)
Distribution
LNS
Mean (95% CI)
IDR
Mean (95% CI)
P value
1 -1.03
-1.18
(-1.18, -0.88) (-1.33, -1.03)
2 -0.94
(-1.10, -0.79)
3 -0.93
(-1.09, -0.77)
4 -0.84
(-1.0, -0.68)
-1.23
(-1.39, -1.07)
-1.21
(-1.35, -1.06)
-1.22
(-1.37, -1.08)
0.17
0.014
0.013
0.001

Difference of Difference, Weight for
Height Z Scores (WHO 2005)
Distribution
interval
Mean Difference
P Value
1 to 2 -0.13 0.25
1 to 3 -0.13 0.19
1 to 4 -0.23 0.02

Nutrition Survey Data 2008-2010 †
Intervention
LNS
2008 GAM
July
(hunger)
2008 GAM
December
(harvest)
2009 GAM
July
(hunger)
2010 GAM
January
(harvest)*
19.2
7.4
11.4
8.5
(15.7-23.1) (5.3-10.3) (9.4-13.6) (6.5-10.5)
IDR
19.5
(16.1-23.5)
9.8
(7.3-12.9)
14.7
(12.6-17.2)
11.7
(8.8-14.7)
†
NCHS reference
* Post harvest delayed into 2010

Results Summary
No statistical difference in the mean WHZ at
baseline between camps
Statistically significant difference in mean
WHZ at distributions 2, 3 and 4 between
camps
Statistical difference in the difference in
differences of WHZ
Baseline and distribution 4

Political and security context
Limitations
Expulsion of ACF forced program implementation in their
absence
Staff capacity and turnover within implementing partners
Communication with sheikhs IDR camp
Small sample size
High default rate due to cultivation period and casual labor
Database management
Lack of dedicated project staff

Conclusions
Blanket distributions were successful in both
LNS and IDR camps at maintaining levels of
acute malnutrition similar to rates in the nonhunger
period
LNS statistically performed better
Viable option in this context
Translation mean WHZ change into
programmatic impact

Future
Replication with larger sample size and longer follow-up
Cost effectiveness
Program Design
Timing and duration of supplementation
Distribution mechanisms
Program guidance
MAM taskforce humanitarian contexts
Multi-agency group formed under the auspices of the
Global Nutrition Cluster

Acknowledgements
ACF France
UNICEF HQ
SMOH, South Darfur UNICEF Sudan
WVI
Surveillance teams
WFP
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
Center for Global Health
International Emergency and Refugee Health